FORM # 1 PEF Health and Safety Conference Registration

Please complete this form if you are being funded by PEF

REGISTRANT INFORMATION

Name of Registrant: _____________________________________ Title:______________________________

Member ID # (PEF members only):__________________________ q Male q Female

Affiliation: q PEF q CSEA q Management q Other

Agency Name:___________________________________ PEF Division #:_____________________________

Work address:_______________________________________________________________________________

Home address (PEF members only):______________________________________________________________

Work Phone: _______________________________ Home Phone (PEF members only): ____________________

Fax Number: _____________________________ E-Mail Address: ___________________________________

HOUSING INFORMATION

Name of Roommate: ___________________________________________________________________________

Telephone number of roommate: __________________________________________________________________

Room Preference: q Non-Smoking q Smoking

Have you confirmed with this roommate? q Yes q No

Select a roommate for me: q

I will be requesting a single room: q

ROOM CHARGES

Please note: Room rates are based on double occupancy. If you chose a double room, there will be no charge. If you chose a single room, you must enclose payment for the difference. Thank you.

Double room (double occupancy)

q Thursday q Friday Total amount due (double room): No charge

Single room (per night, tax included): $55.00

q Thursday q Friday Total amount due (single room):________________

MEAL RESERVATIONS

I will need meals for:

Thursday: q Dinner

Friday: q Breakfast q Lunch q Dinner

Saturday: q Breakfast

Please return this form by December 20, 2002 to: Danielle Little-Thomson

NYS PEF/H&S Conference Registration

1168-70 Troy-Schenectady Road, P.O. Box 12414 Albany, NY 12212-2414

Registration Fee: $35

Total Amount Enclosed: _____________________________